The Prevention Revolution


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Geoff Honnor (ACON) redefines wellness in an evolving HIV epidemic, as well as discussing the context of the UN Goals for reducing HIV transmission 2010-2015 and the ACON response.

This presentation was given at the AFAO Positive Services Forum 2012.

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  • This began and concludes with delivery on commitment. Delivery requires - inter alia - a reinvention of the prevalent treatments discourse which, I'd argue, is still pretty much the mid 90's narrative of toxic treatment and corrosive side effects, which, in turn, positions treatment initiation as 'descent into disease' rather than as wellness generating and hence, ideally delayed for as long as possible.  In order to present an earlier initiation case to our community, we have to reach them and I'd argue that the community-based response isn't best-placed to do that currently.  I can only speak for NSW obviously, but in Sydney, it seems to me that PLHIV tend to use the distance they can create, between themselves and the community-based engagement in place to ostensibly engage them (largely unchanged, in structural terms, since the beginning of the epidemic), as a self-assessed indicator of 'wellness.'  This isn't of course universally the case. Positive Life and PLWHA (Vic) are both delivering innovative and engaging health promotion programs and resources and the Genesis Workshop model, developed initially by ACON here in Sydney, and now used in a number of states, is a standout example of sustained health outcome provision from a 3 day workshop - and also, ironically enough, might well exacerbate the 'distance= wellness ' point by empowering the participants not to need us on an ongoing basis. It also operates (rather than simply being designated) as a peer-delivered program - increasingly a rarity.  I should also mention that, Positive Life (in its earlier PLWHA framing) initiated an Australian sector discussion about sexually adventurous gaypoz men and the sexual privileging that can attach to diagnosis in sexual subcultures, through its 'Sex Pigs' campaign. It was thought to be deeply dangerous at the time but it initiated a new frame of engagement and understanding that continues.  And of course the treatments advocacy/info/support core component activity continues albeit with sector knowledge and expertise increasingly concentrated in a smaller number of individuals.  However, I'd argue that in NSW, our HIV+ health promotion program service provision - still pretty much delivered from the complex, uncoordinated mosaic of government and non-government agencies constructed as early epidemic response - is largely consumed by the 20%-30% of PLHIV who do remain engaged with us - they're largely DSP-reliant, often present with a range of life challenges (HIV - optimally suppressed in most cases - tends not to be among the most significant of these) are more likely to be older and more likely to access the direct assistance programs that organisations like BGF originally set up to provide support for men dying from AIDS.  The service provision needs here are real and pressing and the clinical/care and support services and programs in place (often confused with health promotion) do represent optimal alignment with them.  But whether these service provision needs are optimally met by diagnosis-centric health promotion programs aimed at PLHIV-generic 'wellness,' is to say the least, debatable. A debate we're not having it seems to me.  It's the case, I think, that the population 'snapshot' in the service delivery frame tends to become understood as 'the population' and hence the notion of PLHIV tends to shape solely in the context of pathology and health deficiency. This in turn, I'd suggest, offers up a public face of HIV lived experience that is at odds with the extraordinary span of the reality.  I'd argue that this one-dimensional take is informed and enabled by both the 'worst case scenario' framing of living with HIV that has historically 'worked' in policy and advocacy and fundraising settings and the inability to discuss 'living well with HIV," in a public sense, in anything other than passing reference terms - always heavily qualified by reflexive reference to the much greater degree of difficulty encountered by others.  The gay men's prevention imperative is also relevant here in that an evolving epidemic dynamic, satisfactory ‘successor’ to the perfect prevention paradigm encapsulated in the pre-treatment rendering of, diagnosis = death (itself never clearly owned as a spent force) has never really emerged.  Attempts to secure risk reduction adherence via florid depictions of lived HIV experience have limited traction with the target demographic and also play into the 'current moment' conundrum for community-based gay men's health promotion response that shapes as inevitable darkness and disaster on one side of diagnosis and the ability/skills to effectively manage diagnosis within a normative life experience that eschews any need for the assumption of 'disease identity'  I'd suggest that overwrought prophecies of PLHIV being drowned in a tidal wave of HIV-related premature onset aging, (based on very early/preliminary research findings), were able to gain traction and dominate sector discourse - pretty much to zero effect in terms of health promotion program ROI- for two years because they played directly into the preferred public rendering of HIV lived reality and were often offered by PLHIV who self-identified with the syndrome. It's a brave individual who would challenge that rendering given the circumstances.  Later research findings certainly confirm the reality of the POA syndrome, but suggest that POA is not as prevalent as was earlier suggested and is subject to the significant degree of individual case variability that's always characterised HIV. It seems to be concentrated in the cohort of heavily treated (often monotherapy-initiated) long term survivors - particularly in the context of presentation with one or more comorbidities. The degree to which disease progression, long-term Rx impact and lifestyle factors intersect is unclear but current research is ascribing more prominence to lifestyle factors than was previously the case.  So, given this context, if there is a potential health promotion initiative or program shaping from the experiences of 'living well' - what does it mean? How is it formed? How is it sustained when it’s pretty much in a 'no go' zone?  Equally, the circumstances of many PLHIV who do engage seem to have [unconsciously]fostered a culture of 'them and us' between the HIV positive gay men who work in the HIV sector (probably in larger numbers now than at any time in the epidemic) and the HIV positive gay men who comprise the significant number of service recipients.  Broadly, the former are largely living the 'wellness' experience (though without any public acknowledgement, or perhaps even awareness, of that being the case), the latter are less likely to be doing so. The latter are not only termed ‘clients’ but also it seems increasingly referenced completely as 'clients' rather than 'peers' and distanced from the providers by an increasingly patient-framed engagement  Yet, interestingly, (and possibly ironically) we seemingly have no problem constructing forms of HIV+ program engagement based on the assumption that a positive diagnosis automatically creates a shared sense of perspective, outlook and community that transcends all else.  As an aside, when I inherited responsibility for the successor service model to the former Luncheon Club in January this year, it struck me that the guys attending the meal services - far from being the high dependence, complex needs 'high maintenance' service provision ask of sector legend (though it's certainly in the mix) were in fact pretty much like me: - gay men, HIV positive, of middle years, guys I'd lived and loved with and shared experience. The only significant point of separation between us probably amounts to about 3 paydays. The LC was never the population level response to poverty that its founder asserted. It was and is a 'club' of people who - meal services aside - find a health promoting sense of place and belonging in being there.  The 'search' questions that emerge from all of this seem to shape as: To what extent can/does the currently framed community- based HIV+ health promotion program response deliver effectively against the improved quality of life/wellbeing, 'standard' strategic indicators? If it doesn't, what needs to change? What does 'living well' with HIV actually mean in any shared sense and is/should that understanding (and the on flow health outcome benefits and impacts) [be] integral to health promotion program development. If it is, how do we speak about and accommodate it, honestly and openly, in the context of public health, advocacy and prevention imperatives.   
  • The Prevention Revolution

    1. 1. Aux Armes Citoyens!The Prevention Revolution …and redefining wellness in anevolving HIV epidemic dynamic.. Geoff Honnor Director, HIV/Sexual Health
    2. 2. Disclaimer!• The content of this presentation should not be interpreted as an officially endorsed ACON position.• The opinions and views are those of the presenter and are aimed at provoking discussion and reflection……..
    3. 3. Outline• The Prevention Revolution• The ACON Response• Organisational Restructure• New Prevention Priorities• What‟s Wellness Got To Do With It?• Redefining HIV Health Promotion• Challenges, Possibilities and Potential
    4. 4. UN Strategy Goals 2010-2015• Sexual transmission of HIV reduced by half, including among young people, men who have sex with men and transmission in the context of sex work• Vertical transmission of HIV eliminated, and AIDS-related maternal mortality reduced by half• All new HIV infections prevented among people who use drugs• Universal access to antiretroviral therapy for people living with HIV who are eligible for treatment• TB deaths among people living with HIV reduced by half
    5. 5. UN Strategy Goals 2010-2015 (cont) • People living with HIV and households affected by HIV are addressed in all national social protection strategies and have access to essential care and support . • Countries with punitive laws and practices around HIV transmission, sex work, drug use or homosexuality that block effective responses reduced by half. • HIV-related restrictions on entry, stay and residence eliminated in half of the countries that have such restrictions • HIV-specific needs of women and girls are addressed in at least half of all national HIV responses Zero tolerance for gender-based violence
    6. 6. The June 2011 Moment…..• Thirty years into the AIDS epidemic, and 10 years since the landmark UN General Assembly Special Session on HIV/AIDS, leaders came together at the 2011 UN General Assembly High Level Meeting on AIDS from 8–10 June 2011 in New York.• They reviewed progress and adopted a new Political Declaration that includes new commitments and bold new targets which will create momentum in the AIDS response.• Australia took a lead role in achieving General Assembly endorsement for the targets
    7. 7. UN Global HIV Prevention Targets“By 2015 we will………………………..• Reduce sexual transmission of HIV by 50 per cent• Reduce HIV transmissions through injecting drug use by 50 per cent• Eliminate mother-to-child HIV transmissions
    8. 8. “For a prevention revolution, we need tocombat public hypocrisy on sexual matters,build AIDS competencies and systematicallypromote sexual and reproductive health andrights.”Michel Sidibe, UNAIDS Executive Director
    9. 9. The Australian ResponseMomentum building through 2010 -11 as new researchfindings emerge:  Pre-exposure prophylaxis (iPrEx)  Treatment as prevention (HPTN 052)  „The validation of the Swiss Consensus Statement‟  The San Francisco Experience And Bill Whittaker offers a challenge to the Australian HIV sector at the Australasian HIV/AIDS Conference in September 2011……
    10. 10. “Now is the opportunity for us to embrace"combination prevention", re-double our efforts andset bold HIV prevention targets aligned with the 2011UN Declaration, to include: • Reducing sexual transmission of HIV among men who have sex with men by 80 per cent by 2015. • Eliminating HIV transmission from injecting drug use by 2015. • Eliminating HIV transmission among sex workers and clients by 2015. • Commit to achieving a 90% ARV treatment uptake rate by 2013
    11. 11. ACON Response• The ACON Board fully endorsed the “Canberra Challenge” in November 2011 and committed the agency to reorient towards the program priorities required• NB: The Board committed to, “ambitious targets,” noting that they would need to be developed in collaboration with Australian and NSW HIV prevention partnership stakeholders.
    12. 12. Draft NSW Goals and Targets• Vision: To achieve the virtual elimination of HIV transmission by 2018.• Targets. By 2015, – To sustain the virtual elimination of mother to child HIV transmission – To sustain the virtual elimination of HIV transmission among people who inject drugs – To sustain the virtual elimination of HIV transmission in the sex industry in NSW – To sustain the virtual elimination of HIV transmission among Aboriginal Populations
    13. 13. Draft NSW Goals and Targets• Targets (continued). By 2015, – To reduce the sexual transmission of HIV by 50% • Gay and homosexually active men.• And, by 2015: – To achieve 90% of people diagnosed with HIV on treatment – To increase median CD4 count at HIV dx to 640 cells/µl – To increase the no. of needles / syringes distributed by 40% – Other? Needle sharing? Late diagnosis? Heterosexual transmission? Service access for priority populations?
    14. 14. Opportunities Presenting. • Emerging combination prevention options, in conjunction with appropriate infrastructure support, offer the best chance since the protease moment to drive infections down • Current/new prevention priorities largely in alignment with current priorities – increase in emphasis, sharper focus and additional approaches required • We have to seize the moment – „wait and see‟ isn‟t an option • Signing up to ambitious – but achievable - 2015 targets will provide the mobilising factor And everything changes……………………….
    15. 15. Opportunities into Action……. 2011-12 Feb – Nov 2011 Organisational review/restructure process Nov 2011 ACON commitment to UN Goals and program priorities Nov 2011 – June 2012 Planning/implementing agency and sector response July 2012 - New era delivery commences
    16. 16. Organisational Review/Restructure = Fit for purpose • First - re-energising Gay Men‟s Prevention (GMP) then agency-wide • New structure launched 4 Jan 2012 • HIV/Sexual Health Division - all NSW Health funded HIV/STI health promotion programs managed in one divisional frame – cross communication is key. • Development/delivery of entire GMP/health promotion response (across serostatus) now from one management/team structure entity • New agency structure = greater flexibility for - and responsiveness to - service reorientation and/or program redeployment when/if required
    17. 17. 3 Key Drivers for delivery • In the short-to-medium term we need to focus on 3 priorities 1. Increase Testing 2. Rethink, reconsider, reinvent our gay men‟s health promotion response 3. More PLHIV on treatment, earlier What else …
    18. 18. Reinventing our gay men’s health promotion response If most HIV+ gay men in NSW can identify little or no need for – or value in -regular engagement with our programs and services…. they’re probably right
    19. 19. What do we need to do? • Celebrate gay men and being gay men • Deliver on our commitment • Question what we do, invite and enable internal discussion and debate • Conceptualise and develop new education and health promotion models; and • Reflectively consider our own sexual practice, lived experiences of serostatus, resilience and vulnerability,in developing new program models • Less “provider/client” points of difference focus; more „gay men‟ similarities focus • Renew and redefine interactive community engagement – what can/does community give us?
    20. 20. Key program renewal tasks • Reorient the gay men‟s HIV prevention response so services and programs align with prevention goals and targets. • Implement our new program engagement commitment to sexually adventurous gay men • Specific focus on undiagnosed men in primary infection • Deliver on commitment to explore beyond diagnosis linkage to identify the drivers and agency that enable HIV+ gay men to live well in self-defined terms
    21. 21. Earlier Initiation of Treatment
    22. 22. What must change?• More flexibility in clinical guidelines and practice• The dominant mid 90‟s treatment narrative – debilitating, toxicity, side effects…”for your health‟s sake, delay starting for as long as possible”
    23. 23. How Must It Change?• Greater flexibility within guidelines to enable earlier commencement of treatment• Prioritise developments/benefits of treatment educational/social marketing to/with/for PLHIV• Conceptualise, build and deliver a more effective and dynamic health promotion relationship with PLHIV: requires significant – and honest - rethinking across the whole sector –
    24. 24. Challenges to Change• Health benefit first, prevention benefit second• The primacy of individual choice• Discomfort with making treatment too sound „easy‟• Ease of access to dispensed medication• Cost
    25. 25. The Living Well Conundrum: • The majority of GMHIV in NSW have little or no regular contact with the community-based health promotion response in place to engage them. • Variations on „improved quality and life and wellbeing‟ provide standard strategic and program delivery framing for HIV health promotion. • However, the practice focus – continually conflated and confused with the sector understanding of care and support – is largely constrained to achieving judicious alignment of HIV clinical indicators.
    26. 26. The LWC Questioned • Yet, two areas where we do have proven HP traction and appeal, are the Genesis Project and the work (initially conceptualised and developed by Kathy Triffitt at Positive Life) acknowledging and responding to issues of GMHIV sexual practice; and specifically, within an energised and sometimes serostatus-privileged sexual sub-culture. • The ethos in both instances is decidedly post-clinical markers, so what might this tell us?.
    27. 27. “There is a fundamental flaw in the debate about HIV these daysthat is never discussed. The public discussion about living withHIV is pretty much always about what an awful thing it is, when,for most gay men who seroconverted in the last ten years, lifehas gone on as usual, they haven’t been sick, they haven’tstopped work, they haven’t had side effects from their meds, butif you try to say that, it’s ‘sending the wrong message’, on someassumption that people are stupid and have to be scared intolooking after themselves. Meanwhile, thousands of gay men withHIV are working out for themselves how to live their life and plana future.”(Comment at Dr George Forgan-Smith‟s „The Healthy Bear Blog‟ 2011)